Joel E. Streim

Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief Instrument of Mental Status

OBJECTIVES: To test the accuracy of a brief cognitive assessment of nursing home (NH) residents and to determine whether facility nurses can reliably perform this assessment.

Overview of Significant Changes in the Minimum Data Set for Nursing Homes Version 3.0

The Minimum Data Set (MDS) is a standardized assessment that is completed on all residents admitted to Medicare certified nursing homes in the US. It is also completed on all residents admitted to Veteran Health Administration Community Living Centers. Its content addresses multiple domains of resident health and function and is intended to facilitate better recognition of each residents needs. A new version of the MDS, MDS 3.0, was implemented in October, 2010. This article highlights significant clinical changes found in the MDS 3.0, including new structured resident interviews to assess mood, preferences, pain and cognition; inclusion of the Confusion Assessment Method to screen for delirium; revised psychosis and behavior items; revised balance and falls sections; revised bladder and bowel assessment items; revised pressure ulcer assessment items; revisions to the nutrition items; items reporting on resident expectations for return to the community; and changes to race/ethnicity item and language report. These changes aim to improve the clinical utility of these assessment items.

All-Cause 1-, 5-, and 10-Year Mortality in Elderly People According to Activities of Daily Living Stage

To examine the independent association between five stages of activities of daily living (ADLs) and mortality after accounting for known diagnostic and sociodemographic risk factors.

A Randomized, Double-Blind, Placebo-Controlled Study of Aripiprazole for the Treatment of Psychosis in Nursing Home Patients with Alzheimer Disease

OBJECTIVE To evaluate the efficacy and safety of aripiprazole treatment for psychotic symptoms associated with Alzheimer disease (AD). METHODS In this parallel group, randomized, double-blind, placebo-controlled, flexible-dose trial, institutionalized subjects with AD and psychotic symptoms were randomized to aripiprazole (n = 131) or placebo (n = 125) for 10 weeks. The aripiprazole starting dose was 2 mg/day, and could be titrated to higher doses (5, 10, and 15 mg/day) based on efficacy and tolerability. RESULTS No significant differences in mean change [2 x SD] from baseline between aripiprazole (mean dose approximately 9 mg/day at endpoint; range = 0.7-15.0 mg) and placebo were detected in the coprimary efficacy endpoints of Neuropsychiatric Inventory-Nursing Home Version (NPI-NH) Psychosis score (aripiprazole, -4.53 [9.23]; placebo, -4.62 [9.56]; F = 0.02, df = 1, 222, p = 0.883 [ANCOVA]) and Clinical Global Impression (CGI)-Severity score (aripiprazole, -0.57 [1.63]; placebo, -0.43 [1.65]; F = 1.67, df = 1, 220, p = 0.198 [ANCOVA]) at endpoint. However, improvements in several secondary efficacy measures (NPI-NH Total, Brief Psychiatric Rating Scale Total, CGI - improvement, Cohen-Mansfield Agitation Inventory and Cornell Depression Scale scores) indicated that aripiprazole may confer clinical benefits beyond the primary outcome measures. Treatment-emergent adverse events (AEs) were similar in both groups, except for somnolence (aripiprazole, 14%; placebo, 4%). Somnolence with aripiprazole was of mild or moderate intensity, and not associated with accidental injury. Incidence of AEs related to extrapyramidal symptoms was low with aripiprazole (5%) and placebo (4%). CONCLUSIONS In nursing home residents with AD and psychosis, aripiprazole did not confer specific benefits for the treatment of psychotic symptoms; but psychological and behavioral symptoms, including agitation, anxiety, and depression, were improved with aripiprazole, with a low risk of AEs.

Change in Disability Follows Inpatient Treatment for Late Life Depression

OBJECTIVES: The objective of this study was to examine the relationship between functional disability and improvement in late life depression after acute inpatient treatment.

Activity of Daily Living Staging, Chronic Health Conditions, and Perceived Lack of Home Accessibility Features for Elderly People Living in the Community

OBJECTIVE: To examine the cross‐sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community‐dwelling adults aged 70 and older.

Heuristic Comparison of Sertraline With Nortriptyline for the Treatment of Depression in Frail Elderly Patients

Studies have demonstrated that the selective serotonin reuptake inhibitor antidepressants have similar efficacy to other agents, such as tricyclic antidepressants. However, data are limited for direct comparisons with other antidepressants. The authors conducted a contemporaneous comparison of nursing home residents treated with open-label sertraline in doses up to 100 mg/day with nursing home residents treated in a double-blind randomized study of low vs. regular doses of nortriptyline. There were 97 patients enrolled in the study (28 treated with sertraline), with an average treatment duration of 55 days. There were no differences in the tolerability of sertraline vs. nortriptyline. However, in this group of frail older adults, sertraline was not as effective as nortriptyline for the treatment of depression.

Alcohol abuse: a source of reversible functional disability among residents of a VA nursing home

The prevalence of psychiatric disorders was determined in a sample of 196 VA nursing home residents who were interviewed using the modified Schedule for Affective Disorders and Schizophrenia (mSADS). Of the 160 subjects for whom data were available, 86% had a diagnosis of at least one psychiatric disorder. The prevalence of clinically significant cognitive impairment was 60.6% and of major depression 13.8%. Of 110 residents for whom alcohol histories were obtained, 32 (29%) had a lifetime diagnosis of alcohol abuse. The degree of impairment in activities of daily living improved significantly from the time of admission to the time of the evaluation (average 1.4 years) among those who were recently abusing alcohol compared to those who formerly abused alcohol and those who never abused alcohol. The effect is clinically as well as statistically significant and has the potential benefit of reducing caregiver burden and health care costs for the elderly.

Pharmacologic treatment of depression in nursing home residents: a mental health services perspective.

Over the past 10 to 15 years, there has been marked progress in clinical research on depression in nursing home residents. There have also been significant changes in federal regulations designed to improve the quality of care. In 1987, only 10% of nursing home residents diagnosed with depression were receiving treatment, but by 1999, 25% of all residents were receiving antidepressants. We report on two studies: one demonstrating that treatment for depression has a substantial, ecologically relevant impact in the nursing home and another demonstrating that profound changes have occurred in the clinical epidemiology of depression and its treatment in the nursing home. Although the numbers of nursing home residents receiving antidepressants have increased dramatically, there are now second-generation problems that must be addressed to ensure the delivery of effective treatment. Developing models to ensure quality of care will require focused mental health services research.

A conceptual framework for rejection of care behaviors: review of literature and analysis of role of dementia severity.

Rejection of care behaviors is common in the geriatric population, especially among patients with dementia. Nonetheless, the concept of rejection of care is not well defined and existing psychosocial theoretical models fall short of capturing complex relationships between factors associated with rejection of care. We propose a definition of rejection of care and develop a conceptual framework of rejection of care incorporating 7 components: intrinsic factors, match between needs and environmental resources, behavior state, antecedents, individual preferences, rejection of care behaviors, and consequences. A literature search yielded 55 studies that examined the associations between rejection of care and factors of the conceptual framework. We quantitatively synthesized studies focused on dementia severity and rejection of care. The literature review demonstrated that rejection of care is more prevalent among patients with dementia or functional impairment, associated with some mutable factors, and is triggered by specific antecedents in the context of daily personal care provision and associated with various adverse outcomes. The meta-analysis provided evidence that severe dementia is associated with higher likelihood of developing rejection of care behaviors compared with mild to moderate dementia. We also found that research on unmet needs, antecedents, and individual preferences has been scarce. The direction of further research is discussed.